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The Canadian taxpayer is an owner of the healthcare system and the owners have a right to be heard. This article encourages leaders both formal and informal to create cultures that promote ASKing questions to test assumptions held, LISTENing to hear the patient voice, and TALKing with patients and families to create new conversations and narratives. Looking at the label, “healthcare system” what’s your contribution to creating health, how will you dedicate yourself to caring about the healthcare consumer and care provider, and what will be your role in creating a new and improved system? An implied question at the foundation of the article is this: Is the difference between managing and leading a difference of empathy?

The lead paper, "Responsibility for Canada's Healthcare Quality Agenda: Interviews with Canadian Health Leaders," is a valuable contribution to the quality and safety improvement conversations taking place across the country. My commentary suggests a dramatic convergence of social, economic, demographic and technological forces has brought healthcare to a threshold of a perfect storm. To brace ourselves against this storm, I have suggested that we need to understand the system not as a structure but as relationships. I argue that alignment is not a concept that is particularly well understood - and we tend to focus almost exclusively on the component of structure.

It is widely recognized that Ontario's Wait Time Strategy is a significant change management initiative. But has the province achieved the goal that it set out for itself in November 2004? This article answers this question, beginning with a brief overview of the major inputs or foundational building blocks of the strategy, followed by a detailed analysis of the major outputs or outcomes of the strategy to date.

Ontario's Wait Time Strategy--a significant change management initiative--is designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas by December 2006 (cancer surgery, cardiac revascularization procedures, cataract surgery, hip and knee total joint replacements, and MRI and CT scans). These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services beyond 2006. Change management initiatives are initially successful because of the significant time, attention and resources that are dedicated to the start-up effort. Many initiatives lose their momentum and impact and ultimately fail in the long run since it is difficult to sustain this level of intensity. The probability of success increases if a culture is developed to sustain the initiative into the future. A pivotal element for this sustained culture is accountability for achieving results. If Ontario is to reduce waits for quality healthcare services over the long term, it must shift from a paradigm where no one--or only a few--are accountable for achieving a particular set of results to one where a wide range of players is accountable for achieving a broad range of results. This includes explicit accountabilities of the public, healthcare providers (including physicians, other healthcare providers, professional associations and regulatory bodies), government and Local Health Integration Networks. Tools required to support these accountabilities include developing leaders, aligning incentives to reinforce what needs to be achieved, and developing information systems to provide the data needed to make decisions, and manage and improve performance.

Expert panels have been widely used in healthcare as a way of bringing knowledgeable people together to examine issues and identify solutions in well-defined areas. Various terms have been used to describe these groups of experts such as "consensus panels," "blue ribbon panels" and "expert committees or panels." Regardless of the term used, panels of healthcare experts have a history of providing invaluable advice to policy- and decision-makers.

Ontario's Wait Time Strategy was designed to improve access to healthcare services in the public system by reducing the time that adult Ontarians wait for services in five areas-cancer surgery, cardiac revascularization procedures (cardiac surgery, percutaneous coronary intervention, diagnostic catheterization), cataract surgery, hip and knee total joint replacements and MRI and CT scans. These five are just the beginning of an ongoing process to improve access to, and reduce wait times for, a broad range of healthcare services.

Ensuring that patients receive timely, high-quality healthcare is the highest priority of Ontario's hospitals, physicians and nurses. Given that the emergency department (ED) is often the "front door" to our healthcare system, developing approaches to improve access and flow in the ED is important - made more challenging by rising patient demand and acuity. Long-standing efforts to improve the ED system have outlined promising approaches and pushed access and flow up the priority list. Recently, in partnership with the Ministry of Health and Long-Term Care (MOHLTC), several Ontario hospitals participated in an intensive and sustained effort to improve access and flow, with promising results. Participants in these efforts described the initiatives as transformational, and the results have been promising and sustained. This article chronicles the efforts of three hospitals to enable other hospitals, physicians and nurses to learn from these experiences and gain confidence that a similar impact can be achieved in their facilities. Specifically, it discusses the following: The three pillars of sustainable transformation. Hospital case studies. St. Joseph's Health Centre (SJHC), Toronto. London Health Sciences Centre (LHSC) - University Hospital. University Health Network (UHN) - Toronto General and Toronto Western. Advice for other hospitals

In many ways SARS unmasked some painful truths about our existing system. Throughout the crisis we had to face head-on the unintended outcomes that flow from a healthcare delivery system designed as a series of unconnected silos.